Guidelines Summary

ADA: Position statement on type 1 diabetes in children and adolescents

In August 2018, the American Diabetes Association released a position statement on type 1 diabetes in children and adolescents, which included the following guidelines^{[70, 71]}:

Consult a pediatric endocrinologist before diagnosing type 1 diabetes when isolated glycosuria or hyperglycemia is discovered in patients with acute illness in the absence of classic symptoms
Differentiating type 1 diabetes, type 2 diabetes, monogenic diabetes, and other forms of diabetes is based on patient history and characteristics, as well as on laboratory tests, such as an islet autoantibody panel
The majority of children with type 1 diabetes should be treated with intensive insulin regimens using multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
A _1C should be measured every 3 months
Blood glucose levels should be monitored up to 6-10 times daily
Continuous glucose monitors (CGM) should be considered in all children and adolescents with type 1 diabetes; the benefits of CGM correlate with adherence to ongoing use of the device
Blood or urine ketone levels should be monitored in children with type 1 diabetes in the presence of prolonged/severe hyperglycemia or acute illness
Individualized medical nutrition therapy is recommended for children and adolescents
Exercise is recommended, with a goal of 60 minutes a day of moderate to vigorous aerobic activity, along with vigorous muscle-strengthening and bone-strengthening activities at least 3 days a week
It is important to frequently monitor glucose before, during, and after exercise (with or without CGM use) to prevent, detect, and treat hypoglycemia and hyperglycemia
All individuals with type 1 diabetes should have access to an uninterrupted supply of insulin; lack of access and insulin omissions are major causes of diabetic ketoacidosis
Glucagon should be prescribed for all individuals with type 1 diabetes, and caregivers or family members should be instructed regarding administration
Once the child has had diabetes for 5 years, annual screening for albuminuria, using a random spot urine sample (morning sample preferred to avoid effects of exercise) to assess the albumin-to-creatinine ratio, should be considered at puberty or at age greater than 10 years, whichever occurs earlier
Once the youth has had diabetes for 3-5 years, an initial dilated and comprehensive eye examination is recommended at age 10 years or after puberty has started, whichever is earlier, and an annual routine follow-up is generally recommended
For adolescents who have had type 1 diabetes for 5 years, consider an annual comprehensive foot exam at the start of puberty or at age 10 years, whichever is earlier
Blood pressure should be measured at each routine visit; children who have high-normal blood pressure (systolic blood pressure [SBP] or diastolic blood pressure [DBP] at 90th percentile for age, sex, and height) or hypertension (SBP or DBP at 95th percentile for age, sex, and height) should have blood pressure confirmed on 3 separate days
Initial treatment of high-normal blood pressure (SBP or DBP consistently at the 90th percentile for age, sex, and height) includes dietary modification and increased exercise for weight control; if target blood pressure is not reached within 3-6 months after lifestyle intervention, consider pharmacologic treatment
Because of their potential teratogenic effects, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) should be considered for initial pharmacologic treatment of hypertension after reproductive counseling
The blood pressure treatment goal is consistently less than the 90th percentile for age, sex, and height
If low-density lipoprotein (LDL) cholesterol is within an acceptable risk level (< 100 mg/dL [2.6 mmol/L]), a lipid profile every 3-5 years is reasonable
If lipid levels are abnormal, initial therapy should consist of optimizing glucose control and initiating a Step 2 American Heart Association diet (restricting saturated fat to 7% of total calories and dietary cholesterol to 200 mg/day)
After age 10 years, consider adding a statin if, despite 6 months of medical nutrition therapy and lifestyle changes, LDL cholesterol remains greater than 160 mg/dL (4.1 mmol/L) or LDL cholesterol remains greater than 130 mg/dL (3.4 mmol/L) with one or more cardiovascular disease (CVD) risk factors present (after reproductive counseling because of the potential teratogenic effects of statins)
The LDL therapy goal is less than 100 mg/dL (2.6 mmol/L)
In children with type 1 diabetes, consider testing for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis
In children and adolescents with type 1 diabetes, an A _1C target of less than 7.5% should be considered but individualized
Glucose (15 g) is preferred treatment for conscious individuals with hypoglycemia (blood glucose < 70 mg/dL [3.9 mmol/L]), but any form of carbohydrate may be used; treatment should be repeated if self-monitoring blood glucose (SMBG) 15 minutes after treatment shows hypoglycemia is still present; when blood glucose concentration returns to normal, consider a meal or snack and/or reduce insulin to prevent recurrence of hypoglycemia
In patients with classic symptoms, blood glucose measurement is sufficient to diagnose diabetes (symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL [11.1 mmol/L])
Measure thyroid-stimulating hormone concentrations when the patient is clinically stable or once glycemic control has been established; if normal, suggest rechecking every 1-2 years (or sooner if the patient develops symptoms or signs that suggest thyroid dysfunction, thyromegaly, an abnormal growth rate, or unexplained glycemic variability)
Screen children for celiac disease by measuring IgA tissue transglutaminase antibodies
Criteria for diagnosis of diabetes is fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)
In asymptomatic children and adolescents at high risk for diabetes, if FPG ≥126 mg/dL (7 mmol/L), if 2-hr PG ≥200 mg/dL (11.1 mmol/L), or if A _1C ≥6.5%, testing should be repeated on a separate day to confirm the diagnosis

ADA: Standards of Medical Care in Diabetes

The American Diabetes Association’s Standards of Medical Care in Diabetes-2018 include the following recommendations with regard to children and adolescents with type 1 diabetes^[63]:

At diagnosis and routinely thereafter, youth with type 1 diabetes and parents/caregivers (for patients aged < 18 years) should receive culturally sensitive and developmentally appropriate individualized diabetes self-management education and support according to national standards
Encourage developmentally appropriate family involvement in diabetes management tasks for children and adolescents, recognizing that premature transfer of diabetes care to the child can result in nonadherence and deterioration in glycemic control
Providers should consider asking youth and their parents about social adjustment (peer relationships) and school performance to determine whether further intervention is needed
Assess youth with diabetes for psychosocial and diabetes-related distress, generally starting at age 7-8 years
Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential
The majority of children and adolescents with type 1 diabetes should be treated with intensive insulin regimens, either via multiple daily injections or continuous subcutaneous insulin infusion
All children and adolescents with type 1 diabetes should self-monitor blood glucose levels multiple times daily, including premeal and prebedtime; as needed for safety in specific clinical situations, such as exercise or driving; and for symptoms of hypoglycemia
Continuous glucose monitoring should be considered in children and adolescents with type 1 diabetes, whether they are using injections or continuous subcutaneous insulin infusion, as an additional tool to help improve glycemic control; benefits of continuous glucose monitoring correlate with adherence to ongoing use of the device
Automated insulin delivery systems improve glycemic control and reduce hypoglycemia in adolescents and should be considered in adolescents with type 1 diabetes
Assess for the presence of autoimmune conditions associated with type 1 diabetes soon after the diabetes diagnosis and if autoimmune disease symptoms develop
Measure thyroid-stimulating hormone concentrations at diagnosis when clinically stable or soon after glycemic control has been established; if normal, consider rechecking every 1-2 years (or sooner if the patient develops symptoms suggestive of thyroid dysfunction, thyromegaly, an abnormal growth rate, or an unexplained glycemic variation)
Screen individuals with type 1 diabetes for celiac disease soon after the diagnosis of diabetes by measuring immunoglobulin A (IgA) tissue transglutaminase antibodies, with documentation of normal total serum IgA levels or, if the patient is IgA deficient, IgG tissue transglutamine and deamidated gliadin antibodies
Repeat screening for celiac disease within 2 years of diabetes diagnosis and then again after 5 years and consider more frequent screening in children who have symptoms or a first-degree relative with celiac disease
Individuals with biopsy-confirmed celiac disease should be placed on a gluten-free diet and have a consultation with a dietitian experienced in managing diabetes and celiac disease
Blood pressure should be measured at each routine visit; children found to have high-normal blood pressure (systolic blood pressure or diastolic blood pressure in the 90th percentile or above for age, sex, and height) or hypertension (systolic blood pressure or diastolic blood pressure in the 95th percentile or above for age, sex, and height) should have elevated blood pressure confirmed on 3 separate days
Initial therapy for dyslipidemia should consist of optimizing glucose control and the employment of medical nutrition therapy (using a Step 2 American Heart Association diet) to decrease the amount of saturated fat in the diet
After the age of 10 years, addition of a statin is suggested in patients who, despite medical nutrition therapy and lifestyle changes, continue to have a low-density lipoprotein (LDL) cholesterol level above 160 mg/dL (4.1 mmol/L) or an LDL cholesterol above 130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease risk factors; however, statin use should follow reproductive counseling and implementation of effective birth control, due to the potential teratogenic effects of statins
Elicit a smoking history at initial and follow-up diabetes visits; discourage smoking in youth who do not smoke, and encourage smoking cessation in those who do smoke
Annual screening for albuminuria with a random spot urine sample for albumin-to-creatinine ratio should be performed at puberty or at age 10 years or older, whichever is earlier, once the child has had diabetes for 5 years
When a persistently elevated urinary albumin-to-creatinine ratio (>30 mg/g) is documented with at least two of three urine samples, treatment with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker may be considered and the dose titrated to maintain blood pressure within the age-appropriate normal range; the urine samples should be obtained over a 6-month interval following efforts to improve glycemic control and normalize blood pressure
An initial dilated and comprehensive eye examination is recommended once a youth has had type 1 diabetes for 3-5 years, provided that he/she is age 10 years or older or puberty has started, whichever is earlier
Consider an annual comprehensive foot exam at the start of puberty or at age 10 years or older, whichever is earlier, once the youth has had type 1 diabetes for 5 years

ISPAD: Diabetic vascular complications in children and adolescents

In August 2018, the International Society for Pediatric and Adolescent Diabetes (ISPAD) released clinical practice consensus guidelines on diabetic microvascular and macrovascular complications in children and adolescents. These include the following^[72]:

Commence screening for microvascular complications at age 11 years
Screening for microvascular disease should be performed preconception and during each trimester of pregnancy
Intensive education and treatment should be provided to children and adolescents to prevent or delay the onset and progression of vascular complications
Achievement of target glycemic control will reduce the risk for onset and progression of diabetic vascular complications
Prevention or cessation of smoking will reduce progression of albuminuria and cardiovascular disease
Screening for diabetic retinopathy should start at age 11 years with 2 to 5 years’ diabetes duration
Screening for diabetic retinopathy should be performed by an ophthalmologist or optometrist or a trained, experienced observer, through dilated pupils, with assessment carried out via biomicroscopic examination or fundal photography
Laser treatment and intravitreal injections of anti–vascular endothelial growth factor (VEGF) agents reduce the rate of vision loss for individuals in vision-threatening stages of retinopathy (severe nonproliferative retinopathy or worse and/or diabetic macular edema)
Screen for renal disease using first morning albumin/creatinine ratio as the preferred method.
Blood pressure (BP) should be measured at least annually; hypertension is defined as average systolic BP (SBP) and/or diastolic BP (DBP) that is at or above the 95th percentile for gender, age, and height on three or more occasions
Angiotensin-converting enzyme (ACE) inhibitors are recommended for use in children with diabetes and hypertension; they have been effective and safe in children in short-term studies but are not safe during pregnancy
Screen for lipid abnormalities in the nonfasting state
With regard to macrovascular disease, screening of BP and lipids is recommended, as above; the benefit of routine screening for other markers of macrovascular complications outside the research setting is unclear

ISPAD: Glycemic control targets and glucose monitoring in children, adolescents, and young adults

In July 2018, the ISPAD released clinical practice consensus guidelines on glycemic control targets and glucose monitoring in children, adolescents, and young adults with diabetes. These include the following^[73]:

Glycemic control of children and adolescents must be assessed by both quarterly hemoglobin A1c (HbA1c) measurements and by regular home glucose monitoring; these permit achievement of optimal health in the following ways: (1) by determining with accuracy and precision an individual's glycemic control, including through assessment of each individual's glycemic determinants; (2) by reducing the risks of acute and chronic disease complications; and (3) by minimizing the effects of hypoglycemia and hyperglycemia on brain development, cognitive function, and mood
Regular self-monitoring of glucose (using accurate finger-stick blood glucose [BG] measurements, with or without continuous glucose monitoring [CGM] or intermittently scanned CGM [isCGM]), is essential for diabetes management for all children and adolescents with diabetes
Each child should have access to technology and materials for self-monitoring of glucose measurements to provide for enough testing for optimized diabetes care
When finger-stick BG measurements are used, testing may need to be performed 6-10 times per day to optimize intensive control; regular review of these BG values should be performed with adjustments to medication/nutritional therapies to optimize control
Real-time CGM data particularly benefit children who cannot articulate symptoms of hypoglycemia or hyperglycemia and those with hypoglycemic unawareness
Intermittently scanned CGM can complement finger-stick BG assessments. Although isCGM provides some benefits similar to those of CGM, it does not alert users to hypoglycemia or hyperglycemia in real time, nor does it permit calibration. Without robust pediatric use efficacy data, it cannot fully replace BG monitoring
For children, adolescents, and young adults aged 25 years or younger, ISPAD recommends individualized targets, aiming for the lowest achievable HbA1c without undue exposure to severe hypoglycemia, balanced with quality of life and burden of care
For children, adolescents, and young adults aged 25 years or younger who have access to comprehensive care, a target HbA1c of less than 53 mmol/mol (7.0%) is recommended
A higher HbA1c goal (in most cases below 58 mmol/mol [7.5%]) is appropriate in the following contexts: (1) inability to articulate symptoms of hypoglycemia; (2) hypoglycemia unawareness/history of severe hypoglycemia; (3) lack of access to analog insulins, advanced insulin delivery technology, and CGM, and lack of ability to regularly check BG; and (4) individuals who are “high glycators,” in whom an at-target HbA1c would reflect a significantly lower mean glucose level than 8.6 mmoL/L (155 mg/dL)
A lower goal (6.5%) or 47.5 mmol/mol may be appropriate if achievable without excessive hypoglycemia, impairment of quality of life, and undue burden of care
A lower goal may be appropriate during the honeymoon phase of type 1 diabetes
For patients who have elevated HbA1c, a stepwise approach to improve glycemic control is advised, including individualized attention to the following: (1) dose adjustments, (2) personal factors limiting achievement of the target, (3) assessment of the psychological effect of goal setting on the individual, and (4) incorporation of available technology to improve glucose monitoring and insulin delivery modalities
HbA1c measurement should be available in all centers caring for persons with diabetes
HbA1c measurements should be performed at least every 3 months
Examining variations in HbA1c between centers can assist in evaluating the care provided by health-care centers, including compliance with agreed-to standards to improve therapies and delivery of pediatric diabetes care

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Media Gallery

Possible mechanism for development of type 1 diabetes.
The effects of insulin deficiency.
Representation of activity profile of some available insulins.
Some of the available insulin injection devices.
A selection of available insulin pumps.
Some of the available blood glucose monitors.
Diabetes Sick Day Rules.
Taking Diabetes Back to School.
Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.

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Author

William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH Consultant Paediatric Diabetologist, Bishop Auckland General Hospital, County Durham and Darlington NHS Foundation Trust, UK

William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH is a member of the following medical societies: British Medical Association, International Society for Pediatric and Adolescent Diabetes, Royal College of Paediatrics and Child Health, Royal College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, American College of Endocrinology

Disclosure: Nothing to disclose.

Chief Editor

Sasigarn A Bowden, MD, FAAP Professor of Pediatrics, Section of Pediatric Endocrinology, Metabolism and Diabetes, Department of Pediatrics, Ohio State University College of Medicine; Pediatric Endocrinologist, Division of Endocrinology, Nationwide Children’s Hospital; Affiliate Faculty/Principal Investigator, Center for Clinical Translational Research, Research Institute at Nationwide Children’s Hospital

Sasigarn A Bowden, MD, FAAP is a member of the following medical societies: American Society for Bone and Mineral Research, Central Ohio Pediatric Society, Endocrine Society, International Society for Pediatric and Adolescent Diabetes, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Arlan L Rosenbloom, MD Adjunct Distinguished Service Professor Emeritus of Pediatrics, University of Florida College of Medicine; Fellow of the American Academy of Pediatrics; Fellow of the American College of Epidemiology

Arlan L Rosenbloom, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Epidemiology, American Pediatric Society, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, Florida Chapter of The American Academy of Pediatrics, Florida Pediatric Society, International Society for Pediatric and Adolescent Diabetes

Disclosure: Nothing to disclose.

Acknowledgements

The author would like to thank Dr. Tim Cheetham and Dr. Debbie Matthews, Colleagues at the Royal Victoria Infirmary, Newcastle upon Tyne, for reading through the manuscript and for years of support.